What Is Warfarin (Coumadin, Jantoven)?

Warfarin is the generic form of the brand-name drugs Coumadin and Jantoven, prescribed to treat blood clots.

Blood clots can occur if you have conditions like deep vein thrombosis (DVT) or pulmonary embolus (PE).

Other conditions that might increase your risk of developing blood clots are an irregular heart rhythm known as atrial fibrillation, a recent heart attack, heart valve replacement, or surgeries like a hip or knee replacement.

Warfarin is also used to prevent new blood clots from forming, helping to reduce your risk of stroke or heart attack.

The anticoagulant is designed to keep blood flowing smoothly in your body by decreasing the amount of clotting proteins present in your blood.

First approved by the Food and Drug Administration (FDA) in 1954, warfarin is available in different strength tablets and injections.

According to the FDA, about two million people in the United States take warfarin to prevent blood clots, heart attack, and/or strokes.

Warfarin Warnings

The FDA has issued a black-box warning for warfarin because the drug can lead to severe bleeding that could be fatal.

The risk of bleeding is more likely when you first begin taking the drug or if you are using a higher dose.

One additional concern with warfarin is that it can be difficult for your doctor to determine the correct dosage, because the right dose will vary depending on your age, diet, and use of other drugs.

In 2007, the FDA updated the labeling of warfarin to explain that a person’s genetic makeup might influence how he/she responds to the drug.

Anyone who has a bleeding disorder should not use warfarin.

In addition, you should not use warfarin if you have blood in your urine or stools, bleeding in your brain or stomach, or an infection in the lining of your heart.

You should avoid using warfarin if you need a spinal tap or epidural, if you had a recent surgery, or are anticipating surgery.

During the time you are taking this drug, you’ll need to keep track of the time it takes your blood to clot by undergoing occasional blood tests.

If you are planning to have any surgery, including a dental procedure, make sure your doctor/dentist is aware that you are using warfarin as well as all the other drugs and products you are taking.

You should also avoid getting injections in your muscles as much as possible. If you must get one, use your arm so that any potential bleeding will be easy to detect.

In the event you develop an illness that results in vomiting, diarrhea or fever and it lasts longer than two days, let your doctor know right away since this could impact how the drug works.

Pregnancy and Warfarin

Warfarin has been linked to miscarriage, birth defects, and other abnormalities, and the risks of taking warfarin during pregnancy clearly outweigh the benefits.

Don’t take this medication if you are pregnant unless your doctor has advised you to do so.

There are no studies showing warfarin is present in the breast milk of women using the drug, though the manufacturer has recommended that caution be used when women who are breastfeeding used warfarin.

Warfarin Side Effects

Common Side Effects of Warfarin:

Bloating/gas

An altered sense of taste

Nausea, vomiting, and mild stomach pain

Warfarin is known to cause bleeding, which may be serious or fatal.

Certain groups of people are at a higher risk for bleeding such as those 65 and older as well as those who have high blood pressure or a history of stroke or mini-stroke known as TIA (transient ischemic attack), and/or stomach or intestinal bleeding.

You might also face an increased risk of bleeding if you have serious heart disease, a low blood count, cancer, kidney problems, are in an accident, or have surgery.

Taking medication that contains heparin or other drugs used to prevent blood clots as well as non-steroidal anti-inflammatory drugs (NSAIDs) also makes bleeding more likely.

Warfarin and Skin Necrosis

It’s important to contact your doctor right away if you notice signs of dying skin or skin necrosis, as well as gangrene.

These conditions have been known to happen soon after people start using warfarin.

If you have pain, color or temperature change in any area of your body, seek medical help immediately to prevent amputation.

Call your physician immediately if you have pain in your toes or they look purple or dark in color.

If you have any unusual bleeding, pain, swelling, or discomfort as well as headaches, dizziness, or weakness, seek care right away.

Other signs of a potentially serious problem include coughing up blood or vomiting something that looks like coffee grounds, unusual bruising, nose or gum bleeds, menstrual or vaginal bleeding that is heavier than normal, a cut that takes a long time to stop bleeding, pink or brown urine, and red or black stools.

Emergency help is also required if you have an allergic reaction.

Symptoms range from hives or difficulty breathing to swelling of your face, lips, tongue, or throat.

Warfarin Interactions

Before using this medicine it's important to tell your doctor about all your previous health conditions as well as all the medications, including all prescription, non-prescription, illegal, recreational, herbal, nutritional, or dietary drugs that you are taking.

Prescriptions drugs of concern when taking warfarin include:

Ciprofloxacin (Cipro)

Erythromycin (Erythrocin)

Clarithromycin(Biaxin)

Metronidazole (Flagyl)

Sulfamethoxazole/Trimethoprim (Septra or Bactrim)

Fluconazole (Diflucan)

Amiodarone (Cordarone)

Carbamazapine (Tegretol or Carbatrol)

Phenytoin (Dilantin)

Phenobarbital

The following over-the-counter (OTC) products may also interact with warfarin:

Coumadin FAQ

Q: I am taking 5 mg of Coumadin once daily. What pain medication can I take, if any?

A: Coumadin (Warfarin) is used to help prevent and treat blood clots in the legs, lungs, and those clots associated with heart-valve replacement or an irregular, rapid heartbeat called atrial fibrillation. Many drugs, including aspirin and other pain medicines, may interact with Coumadin. Aspirin and NSAIDs (e.g., ibuprofen, naproxen) interact with Coumadin and increase the risk of bleeding. Do not take aspirin or NSAIDs unless you talk with your doctor first. Tylenol (acetaminophen) is safe to take with Coumadin. Many factors alone or together such as changes in diet and medicines, including herbal supplements, may affect your response to Coumadin.

Q: I take Coumadin because of atrial fibrillation. Will I ever able to discontinue it?

A: People with atrial fibrillation have an increased risk of stroke as a result of blood clots that can form in the heart. As a result, most people are advised to use a treatment to reduce the risk of developing blood clots. In your case, warfarin is being used to prevent clots from forming and will most likely be needed for an indefinite period of time.

Q: I take Coumadin for protein S deficiency. If I take vitamin D3 will it interfere?

A: I cannot find anything in the literature with vitamin D3 interacting with Coumadin (warfarin), but be sure that your health care provider knows you are taking this with the Coumadin. Do not take any OTC or herbal medications or other vitamins without consulting with your physician first. Follow the instructions of your health care provider and read carefully all product packaging associated with any medication that is provided to you.

Q: Is it true there will be a new drug on the market to replace Coumadin?

A: There are drugs being studied in clinical trials that work similarly to Coumadin (warfarin) to treat certain conditions. When they will be approved by the U.S. Food and Drug Administration (FDA) for use in this country is unknown. For additional information regarding Coumadin (warfarin) visit our Web site: http://www.everydayhealth.com/drugs/coumadin

Q: Can Coumadin cause weight gain?

A: Weight gain is not listed as a side effect in Coumadin's package insert. It's important to consult with your physician or healthcare provider about any specific questions regarding your medical conditions or medications, particularly before taking any action.

Q: I take one 2.5 mg Coumadin every day. What can I take to help the pain I have in my back and leg?

A: Coumadin (warfarin) is an anticoagulant (blood thinner) and reduces the formation of blood clots. You should not take acetaminophen (Tylenol), aspirin, or NSAIDs (non-steroidal anti-inflammatory drugs) unless your doctor has told you to. NSAIDs include celecoxib (Celebrex), diclofenac (Voltaren), ibuprofen (Motrin, Advil), indomethacin, naproxen (Aleve, Naprosyn), piroxicam (Feldene), and others. The use of these medications with Coumadin (warfarin) may cause an increased risk of bleeding, a possible side effect of both medications. You may want to talk to your doctor about other treatment options to help with the back and leg pain you are experiencing. For additional information regarding Coumadin (warfarin) you may want to visit our website. http://www.everydayhealth.com/drugs/coumadin

Q: How much vitamin K is allowed when you are taking Coumadin? What does the vitamin K do?

A: It is so important to be aware of the role vitamin K plays when it relates to Coumadin (warfarin) treatment. One of the most important things to remember with Coumadin is to avoid sudden changes in the amount of dietary intake of vitamin K. Vitamin K can decrease the effects of Coumadin in the body. Large amounts of vitamin K are found in foods such as liver, broccoli, brussels sprouts, spinach, Swiss chard, coriander, collards, cabbage, and other green leafy vegetables. Do not change the amount of these foods in your diet without first talking to your doctor. While being treated with Coumadin, it is important to discuss dietary intake of vitamin K with your health care provider and always make sure your blood is being routinely monitored. For additional information regarding Coumadin and Vitamin K, read: http://www.everydayhealth.com/drugs/coumadin.

Q: I take Coumadin. Can I take fish-oil supplements?

A: There is a risk that fish oil can increase the anticoagulant effect of Coumadin (warfarin), resulting in an increased International Normalized Ratio (INR) and an increased risk of bleeding. The interaction can be managed by frequent monitoring of the INR when fish oil is started. Signs of bleeding include nosebleeds, bleeding gums, unusual or easy bruising, and dark urine or stools. Discuss fish oil and the potential need for increased monitoring with your health care provider before starting fish oil. You may also find helpful information at http://www.everydayhealth.com/drugs/coumadin.

Q: My mother is on Coumadin. Is it possible for her to take a fish oil supplement, omega 3 or any vitamins?

A: There is a drug interaction between Coumadin (warfarin) and fish oil or omega 3 that increases the risk of bleeding. The interaction can be managed by frequently monitoring the INR and adjusting the dose of Coumadin as necessary. Patients should consult their healthcare provider before starting fish oil or omega 3 to arrange for more frequent monitoring. Patients should also be aware of the signs of bleeding, including nose bleeds, bleeding gums, bruising easily, and dark urine or stools. Patients should also consult their healthcare provider before starting any multi-vitamin containing vitamin K, as this could interfere with Coumadin. Contact your healthcare provider for more specific recommendations. You may also find helpful information at http://www.everydayhealth.com/drugs/warfarin Sarah Lewis, PharmD

Q: Can I take Tylenol if I am taking Coumadin?

A: Acetaminophen (Tylenol) is listed as a drug reported to interact with Coumadin (warfarin), according to Coumadin package inserts. Data has shown acetaminophen's ability to increase the effect of Coumadin in doses as low as low 2 grams (2,000 mg) per day, particularly when acetaminophen is used for more than one week. Cases of bleeding from this interaction have been reported. However, some data have not shown this interaction.
Derek Dore, PharmD

Q: What is the risk for an 83 year old male drinking two glasses of beer each day while on Coumadin tablets (2.5 mg/day)?

A: In general, avoid drinking alcohol while taking Coumadin (warfarin), as it can increase some of the side effects of this medication. Moderate drinking (one to two drinks per day) may not affect Coumadin in patients with normal liver function. However, binge drinking or drinking large amounts of alcohol may significantly increase the risk of bleeding with Coumadin. Discuss your alcohol use with your healthcare provider and avoid changes in your alcohol consumption. Contact your healthcare provider right away for any signs of bleeding including nose bleeds, bleeding gums, bruising easily, cuts that won't clot, and dark urine or stools. It is important for your healthcare provider to do routine blood work while taking Coumadin. For more specific information, consult your healthcare provider. You may also find helpful information at http://www.everydayhealth.com/drugs/coumadin Sarah Lewis, PharmD

Q: I am on Coumadin and am very confused about what I can and cannot eat. What foods, fruits, vitamins, and supplements should I avoid?

A: Several patients have very similar questions. The most important thing to realize is that it is usually okay to keep your diet the way it is, just as long as you do not vary from the diet. We typically tell people to avoid green leafy vegetables and liver because they contain large amounts of vitamin K, which can throw off your INR (international normalized ratio, a measure of coagulation time) readings. However, as I stated, if these things are in your normal diet, then your provider can accommodate for this by raising the dose a little bit. Contact your nurse or physician in your Coumadin (warfarin) clinic for more information and visit us here: http://www.everydayhealth.com/drugs/coumadin.
Matt Curley, PharmD

Q: I have Factor V Leiden thrombophilia. Is it absolutely necessary to take Coumadin? I cannot get a straight answer from my physician.

A: According to the National Institutes of Health (NIH), people with Factor V Leiden thrombophilia are at a "somewhat higher than average risk" for clots that form in veins. These clots include deep vein thrombosis (DVT) and pulmonary embolism (PE), which can be life-threatening. Coumadin (warfarin) is the standard prevention for DVT and PE. The NIH points out that most people with the genetic mutation that leads to Factor V Leiden thrombophilia never develop an abnormal clot. Your risk depends on whether you have inherited one (from one parent) or two (from both parents) copies of the gene. If you have inherited one copy, your yearly risk of developing a clot is 4 to 8 in 1,000 compared to a normal risk of 1 in 1,000. If you have inherited two copies of the gene, your risk is 80 in 1,000 compared to 1 in 1,000. Your healthcare provider is best able to help you assess your genetic risk and any other medical conditions that put you at risk for clotting. Consult your physician for guidance with treatment decisions based on your specific circumstances. You may also find helpful information at http://www.everydayhealth.com/heart-disease/dvt/index.aspx and http://www.everydayhealth.com/health-information/thromboembolism-deep-vein-thrombosis-and-pulmonary-embolism-what-is-it.aspx Sarah Lewis, PharmD

Q: I am on Coumadin. I stopped taking my multivitamin because it had vitamin K. Is there another multivitamin that you can recommend?

A: Many multivitamins do not contain vitamin K. They include: One A Day Women

Q: My partner is taking Coumadin for blood clots in his legs. He feels quite tired from it and a bit "foggy." Are those normal side effects?

A: I hesitate to say anything because his behavior could be a result of a clot, blockage or a ministroke.Please have your partner evaluated by an experienced physician to ensure that this is not a symptom of a much more serious problem. Matt Curley, PharmD

Q: I take Coumadin due to heart valve surgery 1 year ago. I have for the last 6 months noticed joint and muscle pain , but when I don't take it the pain goes away. Everyone says it's my imagination and quite frankly, I'm getting mad.

A: I understand your concern. The joint and muscle pain may be a symptom of something much more serious. Continue taking the Coumadin (warfarin) as prescribed, and have your physician perform a liver enzyme panel. In addition, let your cardiologist know that you are having these symptoms. While there are many patients that continue to have some aches and pains, often the benefit of warfarin is much larger than its shortcomings, but I assure you it is not your imagination. Thank you for writing and visit us here for more information: http://www.everydayhealth.com/drugs/warfarin Matt Curley, PharmD

Q: Is HCG safe to take when you are on Coumadin?

A: Human chorionic gonadotropin (HCG) is used for female infertility and other conditions resulting from a lack of this hormone. Coumadin (warfarin) is an anticoagulant, or blood thinner, that is used to prevent heart attacks, strokes, and blood clots in veins and arteries. Generally speaking, drug interactions fall into three main categories: Drug-drug (i.e., prescription, over-the-counter, herbals, dietary supplements) interactions occur when two or more drugs react with each other. Drug-diet (food/drink) interactions result from drugs reacting with foods or drinks. Drug-disease interactions may occur when an existing medical condition makes certain drugs potentially harmful. No significant interactions between the specified medications were identified; however, it is possible that there are interactions between these medications that have not been studied or reported. When your doctor prescribes a new medication, be sure to discuss all your prescription and over-the-counter drugs, including dietary supplements, vitamins, botanicals, minerals, and herbals, as well as the foods you eat. Always keep a current list of the drugs and supplements you take and review it with your health care providers and your pharmacist. If possible, use one pharmacy for all your prescription medications and over-the-counter products. This allows your pharmacist to keep a complete record of all your prescription drugs and to advise you about drug interactions and side effects. For more specific information, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. Michelle McDermott, PharmD

Q: Is it safe to stop taking Coumadin (warfarin) after taking it for 9 months?

A: Coumadin (warfarin) is in a drug class called anticoagulants

Q: Is there another foodstuff or over-the-counter medication that will flush the kidneys as well as cranberries do? I am on a coumadin regimen, which excluded cranberries due to the high vitamin K content.

A: The most effective way to "flush" your kidneys is to drink water daily. If you drink 8 glasses of water a day, this is the most effective and natural way to flush toxins from your kidneys. This is also the safest way to do it without any interactions with your coumadin regimen. There are many products that claim to aid in the flushing of kidneys, but they contain many herbal supplements that are not regulated or monitored by the FDA and can pose health concerns. Herbal products will almost always interact with coumadin as well, so they would not be a good choice for your situation. For more specific information, consult with your doctor for guidance based on your health status and current medications, particularly before taking any action. Lori Poulin, PharmD

Q: Once the heart has been put back in rhythm, can you then discontinue the Coumadin therapy?

A: You must consult your physician about stopping Coumadin (warfarin) therapy after your heart has been put back in rhythm; this process is called a cardioversion. The medical literature recommends Coumadin therapy for 4 weeks after cardioversion in some patients. Some people may need to take warfarin for an extended period of time, especially if they have other risk factors for clot formation. Some risk factors include a history of coronary artery disease or stroke, recurring episodes of fibrillations, and other heart conditions. Coumadin inhibits the action of Vitamin K dependant blood clot formation. It is important to maintain a consistent level of Vitamin K intake while taking Coumadin. Large amounts of vitamin K are found in foods such as liver, broccoli, brussels sprouts, spinach, Swiss chard, coriander, collards, cabbage, and other green leafy vegetables. Do not change the amount of these foods in your diet without first talking to your doctor. Contact your physician immediately if you notice any signs of bleeding such as easy bruising, blood in your urine, black or bloody stools, nosebleeds, bleeding gums, or coughing up blood. Coumadin can interact with many other medications. Burton Dunaway, PharmD.

Q: I take Coumadin every day. What herbs and vegetables can I safely eat?

A: Coumadin (warfarin) is a blood thinner used to prevent heart attack, stroke and (blood clots in veins and arteries, but foods that have vitamin K can keep it from working if eaten in large quantities. However, when a person is being adjusted to a dose of Coumadin (warfarin), they should try to keep eating the same types of food, and keep the same medications or OTC (over the counter) products, unless these substances have too much of an effect on the drug. Then, the dose of the blood thinner can be adjusted to the lifestyle. Always let the doctor know if new medications have been added or if old medications have been stopped, as there may be a need to adjust the Coumadin (warfarin) dose at that time. To avoid changing the dose of the blood thinner, you may want to avoid large amounts of liver, cabbage, kale, spinach, brussels sprouts, parsley, collard greens, mustard greens, chard, green leafy vegetables in general, cranberry juice, alcohol, and green tea. If you are unable to eat for days, or have ongoing stomach upset, diarrhea, or fever, you may need and adjustment in dose, so let our doctor know as soon as possible. Coumadin (warfarin) is not fast acting, so it may take a few days to see the level in the blood. Sometimes, other blood thinners are given during the transition. Patti Brown, PharmD

Q: Can you send me a list of foods to stay away from when on Coumadin?

A: Coumadin (warfarin) is a blood thinner used to prevent heart attack, stroke and (blood clots in veins and arteries), but foods that have vitamin K can keep it from working if eaten in large quantities. However, when a person is being adjusted to a dose of Coumadin (warfarin), they should try to keep eating the same types of food, and keep the same medications or OTC (over the counter) products, unless these substances have too much of an effect on the drug. Then, the dose of the blood thinner can be adjusted to the lifestyle. Always let the doctor know if new medications have been added or if old medications have been stopped, as there may be a need to adjust the Coumadin (warfarin) dose at that time. To avoid changing the dose of the blood thinner, you may want to avoid large amounts of liver, cabbage, kale, spinach, brussel sprouts, parsley, collard greens, mustard greens, chard, green leafy vegetables in general, cranberry juice, alcohol, and green tea. If you are unable to eat for days, or have ongoing stomach upset, diarrhea, or fever, you may need and adjustment in dose, so let our doctor know as soon as possible. Coumadin (warfarin) is not fast acting, so it may take a few days to see the level in the blood. Sometimes, other blood thinners are given during the transition. Patti Brown, PharmD

Q: Can Coumadin cause weight gain?

A: Drugs can cause weight gain in several different ways. Some can increase appetite or make you crave certain types of foods like those high in carbohydrates or fat. Other medications may slow down metabolism or cause fluid retention. However, the effect of prescription drugs on body weight is complex. Some drugs have no effect on weight, while others cause weight gain or weight loss. Also, the same medications can cause weight gain in certain individuals and weight loss in others. There are also drugs that initially cause weight loss and then lead to weight gain with long-term use. Most prescription medications associated with changes in body weight affect the central nervous system. These include antidepressants like monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants, and selective serotonin reuptake inhibitors (SSRIs). Mood stabilizers (lithium, valproic acid), antipsychotics, and anticonvulsants have also been linked with weight gain. Other drugs that have been reported to cause weight gain include diabetes medications (insulin, sulfonylureas, and thiazolidinediones), antihypertensive drugs, certain hormonal contraceptives, corticosteroids, antihistamines, some chemotherapy regimens, and antiretroviral protease inhibitors. Coumadin (warfarin) is a blood thinner used to prevent blood clots. The packaging information for Coumadin does not list weight changes as a possible side effect. If you think a drug you are taking is causing weight gain, tell your health care provider. Do not stop any medication or change the dose without first talking to your provider. For more specific information, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. Laura Cable, PharmD., BCPS

Q: Does Coumadin have an effect on the liver, kidneys, etc? What if I ever need surgery? What are the long-term effects of Coumadin?

A: Coumadin (warfarin) (http://http://www.everydayhealth.com/drugs/coumadin) is an anticoagulant that is indicated for prevention of blood clots after strokes, heart attacks, and as a prophylaxis treatment in A-fib. (http://www.everydayhealth.com/senior-health/stroke/index.aspx). Common side effects with Coumadin include nausea, stomach pain, gas and bloating. Potential adverse reactions to Coumadin may include hemorrhage or bleeding from any tissue or organ. Also necrosis or deadening of the skin and other tissues may occur from Coumadin. A search of prescribing information also listed elevated liver enzymes, inflammation of the liver, jaundice, hypotension, and swelling. It is very important to get regular INR or blood checks done by the doctor and let your doctor know of any unusual symptoms you may be experiencing. This is not a complete list of side effects associated with Coumadin, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. When your doctor prescribes a new medication, be sure to discuss all your prescription medications and over-the-counter drugs, including dietary supplements, vitamins, botanicals, minerals and herbals, as well as foods you eat. Always keep a current list of the drugs and supplements you take and review it with your healthcare providers and your pharmacist. If possible, use one pharmacy for all your prescriptions and over-the-counter products. This allows your pharmacist to keep a complete record of all your prescription drugs and advise you about drug interactions and side effects. Tell your health-care provider about any negative side effects from prescription drugs. You can also report them to the U.S Food and Drug Administration by visiting http://www.fda.gov/medwatch or by calling 1-800-FDA-1088. Kimberly Hotz, PharmD.

Q: What are the long-term side effects of Coumadin? I'm concerned about bleeding as I am slightly anemic.

A: Coumadin (warfarin) is an anticoagulant (blood thinner) used to decrease the formation of blood clots. Coumadin is used to prevent heart attacks, strokes and blood clots in veins and arteries. It may also be used for other conditions as determined by your healthcare provider. Some of the commonly reported, and less severe, side effects associated with Coumadin treatment include nausea, vomiting and stomach pain. One of them most serious complications of Coumadin is bleeding. To ensure this medication is working appropriately, your healthcare provider will routinely monitor your blood levels. It is important to take Coumadin exactly as prescribed by your doctor and take it at the same time every day. If any of your blood work comes back abnormally, your doctor may need to adjust your dose of Coumadin accordingly. If your last blood work showed anemia and you are concerned about internal bleeding, it is extremely important to discuss this with your doctor immediately. For more specific information, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. Beth Isaac, PharmD

Q: Does regular or romaine lettuce interact with Coumadin?

A: Coumadin (warfarin) is an anticoagulant or blood thinner that reduces the formation of blood clots. It is used to prevent heart attacks, strokes, and blood clots in veins and arteries. People taking Coumadin need to avoid sudden changes in their diet and in the amount of vitamin K-containing foods that they eat. Vitamin K decreases the effectiveness of Coumadin, so your doctor needs to know if you plan to change your diet. According to the National Institutes of Health (NIH), green leafy vegetables are some of the richest sources of vitamin K. This includes vegetables such as kale, spinach, collards, mustard greens, turnip greens, Swiss chard, and fresh parsley. The NIH recommends not eating more than 1 (1/2 cup) serving of these vegetables per day when taking Coumadin. If these vegetables are not part of your regular diet, it is recommended to avoid them. Vegetables that contain a moderate amount of vitamin K include Brussels sprouts, green leaf lettuce, Romaine lettuce, Endive lettuce, and broccoli. The NIH recommends that people on Coumadin not eat more than 3 servings of these vegetables per day. Low levels of vitamin K are found in vegetables such as iceberg lettuce, red cabbage, and asparagus. The NIH recommends eating these vegetables as desired. Please discuss your diet and vegetable consumption with your doctor and do not make sudden changes in your diet without talking to your doctor first. You may also find helpful information at the NIH's website: www.nih.gov. Your doctor is best able to guide your treatment decisions based on your specific circumstances. For more specific information, consult with your doctor or local pharmacist for guidance based on your health status and current medications, particularly before taking any action. Sarah Lewis, RPh, PharmD

Q: Is coughing a side effect of Coumadin? I could not find this in my information, but several people I know have had coughing problems.

A: Coumadin (warfarin) is an anticoagulant (blood thinner) that reduces the formation of blood clots. It is used to prevent heart attacks, strokes, and blood clots in veins and arteries. Common side effects of Coumadin include nausea, vomiting, stomach pain, gas and bloating. A search of the prescribing information for Coumadin did not specifically list coughing as a side effect. However, there is a risk of bleeding with Coumadin and coughing up blood is listed. Other signs of bleeding include nose bleeds, bleeding gums, easy or unusual bleeding, cuts that won't heal, or dark urine or stools. This is not a complete list of the side effects associated with Coumadin. For more specific information, consult with your doctor or local pharmacist for guidance based on your health status and current medications. When your doctor prescribes a new medication, be sure to discuss all your prescription and over-the-counter drugs, including dietary supplements, vitamins, botanicals, minerals, and herbals, as well as the foods you eat. Always keep a current list of the drugs and supplements you take and review it with your healthcare providers and your pharmacist. If possible, use one pharmacy for all your prescription medications and over-the-counter products. This allows your pharmacist to keep a complete record of all your prescription drugs and to advise you about drug interactions and side effects. Tell your health-care provider about any negative side effects from prescription drugs. You can also report them to the U.S. Food and Drug Administration by visiting www.fda.gov/medwatch or by calling 1-800-FDA-1088. Sarah Lewis, RPh

Q: Are there any bad side effects associated with use of Coumadin?

A: Coumadin (warfarin) (http://www.everydayhealth.com/drugs/coumadin) is an anticoagulant that is indicated for prevention of blood clots after strokes, heart attacks, and as a prophylaxis treatment in A-fib. (http://www.everydayhealth.com/senior-health/stroke/index.aspx). Common side effects with Coumadin include nausea, stomach pain, gas and bloating. A search of prescribing information also reported that Coumadin can sometimes cause severe or fatal bleeding. Bleeding is more likely at the start of treatment or at high doses. It is very important to get regular INR or blood checks done by the doctor. This is not a complete list of side effects associated with Coumadin, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. When your doctor prescribes a new medication, be sure to discuss all your prescription medications and over-the-counter drugs, including dietary supplements, vitamins, botanicals, minerals and herbals, as well as foods you eat. Always keep a current list of the drugs and supplements you take and review it with your healthcare providers and your pharmacist. If possible, use one pharmacy for all your prescriptions and over-the-counter products. This allows your pharmacist to keep a complete record of all your prescription drugs and advise you about drug interactions and side effects. Tell your health-care provider about any negative side effects from prescription drugs. You can also report them to the U.S Food and Drug Administration by visiting http://www.fda.gov/medwatch or by calling 1-800-FDA-1088. Kimberly Hotz, PharmD

Q: I am on Coumadin. I have stayed away from all leafy vegetables. Can I eat squash and beets?

A: Coumadin (warfarin) is in a drug class called anticoagulants. Coumadin is also referred to as a blood thinner. Coumadin is used to prevent the formation of blood clots, or to prevent blood clots from becoming larger in the blood and blood vessels. Coumadin is used in some people who have an irregular heartbeat, prosthetic (replacement or mechanical) heart valves, and people who have had a heart attack. In addition, Coumadin is used to prevent or treat swelling and blood clot in a vein (venous thrombosis) and blood clot in the lung (pulmonary embolism). Coumadin works by reducing the ability of the blood to be able to clot. Coumadin does this by stopping vitamin K-dependent clotting factors from being made. Vitamin K can decrease the blood-thinning effects of Coumadin. According to Coumadin

Q: What vegetables can be eaten when taking Coumadin?

A: Vitamin K is essential for blood clot formation in the body. Coumadin (warfarin) blocks the effects of vitamin K, making it harder for your body to form clots. The amount of vitamin K in your diet can change the effect of warfarin. The medical literature states that you do not have to avoid foods that are high in vitamin K, but it is important to keep your dietary intake of vitamin K consistent. Avoid major changes in vitamin K intake while taking warfarin. Some foods that are high in vitamin K include spinach, broccoli, brussel sprouts, cabbage, collard greens, bib and red leaf lettuce, mustard greens, turnip greens, watercress, parsley, endive, swiss chard, liver, green tea, mayonnaise, canola oil, and soybean oil. Some foods that are low in vitamin K are carrots, green beans, cauliflower, celery, eggplant, cucumber, mushrooms, onions, potato, green pepper, pumpkin, tomato, beef, chicken, turkey, pork, fish, corn oil, peanut oil, safflower oil, and fruits. Foods that have a moderate amount of vitamin K are pickles, green peas, iceberg lettuce, asparagus, avocado, red cabbage, margarine, and olive oil. In order to determine if your warfarin dose needs adjusting, your physician should test your blood periodically. The blood test measures how long it takes for your blood to clot. Many prescription and over-the-counter drugs, vitamins, and herbal supplements, can affect your warfarin level. Do not start, stop, or change doses of any drugs or supplements without first talking with your physician. Try to keep a healthy, well-balanced diet and keep your vitamin K intake consistent. Try to take your warfarin dose around the same time each day. If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Tell your physician immediately if you have unusual bleeding or bruising, black or bloody stools, blood in the urine, or stomach pain. If you would like to submit another question, return to Everyday Health. I hope this helps! Burton Dunaway, PharmD

Q: What does an INR and PT of 1.0 mean for a person, age 83, who takes Coumadin every day? Does it mean she will not clot if she cuts herself?

A: After a person has a stroke, heart attack, DVT (deep vein thrombosis) or if they have a risk factor for them or other conditions for blood clotting, a blood thinner, such as Coumadin (warfarin) may be prescribed so the blood will not be as likely to form a clot again and block the blood vessels. The PT (pro-time) and PTT (partial thromboplastin time) measure the ability of the blood to clot. The INR (international normalized ratio) looks at how effective the blood thinner, such as Coumadin (warfarin) is working. The tests are performed when a blood thinner is started, and then again on a regular basis to make sure the blood thinner is working properly. The tests are done often in the beginning to get the medication to the proper stabilization. To further assist, the patient should try not to start or stop any new medications or at least let the doctor know about them. This includes the blood-thinning pain relievers Motrin/Advil (ibuprofen) and Aleve (naproxen). Aspirin is also a blood thinner and a doctor may prescribe it along with the Coumadin. The diet should also remain as constant as possible, as vitamin K, found in green, leafy vegetables and other foods, can increase clotting. However, Coumadin can be adjusted around medications and diet. The tests will also need to be performed if there are signs of easy bruising and bleeding. Most people who are not on blood thinners have an INR of 1.0 and the number should increase when the blood is thinned. The target INR for blood thinning is 2.0 to 3.0, but in some cases, people need a higher level of 2.5 to 3.5 to keep the blood even thinner. Since the person in question is taking Coumadin (warfarin) and has an INR of 1.0, the blood is thicker, similar to someone not taking the medication. The doctor should be consulted and if new medications, even OTC (over the counter) herbs and supplements were started let them know, as well as any change in diet. For more specific information, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action.
Patti Brown, PharmD

Q: Can Coumadin affect your bladder, such as becoming incontinent?

A: Coumadin (warfarin) is classified as an anticoagulant coumarin derivative and as a vitamin K antagonist. Warfarin acts as a blood thinner. The medication helps to reduce the formation of blood clots. According to medical references, incontinence is not a common reported side effect of Coumadin. If you are experiencing incontinence or other bladder issues, the recommendation is to talk to your physician. Your physician will be able to properly diagnose you and treatment options can be explored after a diagnosis is made. Everyday Health provides valuable information regarding incontinence. Click here to access the articles. Jen Marsico, RPh

Q: I am on warfarin and I have been very tired lately. Do you have a list what I can eat with warfarin and what I can't eat with warfarin?

A: Coumadin (warfarin) (http://http://www.everydayhealth.com/drugs/coumadin) is an anticoagulant that is indicated for prevention of blood clots after strokes, heart attacks, and as a prophylaxis treatment in A-fib. (http://www.everydayhealth.com/senior-health/stroke/index.aspx). Drug interactions: Coumadin and alcohol---Patients should limit 1-2 alcoholic drinks per day or refrain completely from alcoholic drinks. Coumadin and foods with large doses of vitamin K---Patients should keep their vitamin K consumption consistent. Foods rich in vitamin K include green, leafy vegetables, avocados, soy beans, and green tea. Lesser amounts are found in liver, bacon, cheese, butter, cauliflower, and coffee. Snack foods containing the fat substitute, olestra, are fortified with 80 mcg of vitamin K per each one ounce serving so as to offset any depletion of vitamin K that may occur due to olestra interference with its absorption. Whether these foods can alter the effect of oral anticoagulants has not been extensively studied. Large amounts of mango fruit has been associated with increasing absorption of warfarin. Some reports have also indicated that cranberry and cranberry juice can increase bleeding in patients taking warfarin. Kimberly Hotz, PharmD

Q: Since I've been taking Coumadin for a pulmonary embolism, I've started to gain weight, why? I have increased my jogging/running schedule and I am watching what I eat, but it doesn't seem to matter. So does the Coumadin make me gain weight or retain fluids?

A: Coumadin (warfarin) is a blood thinner used to prevent blood clots. The most common side effects with Coumadin include bleeding from any site such bloody nose, bruising, bleeding from gums or blood in urine or stool. Frequent monitoring of blood tests help to reduce the risk of bleeding. It is important to report any bleeding to your doctor right away. Other side effects with Coumadin include edema (swelling, usually in lower extremities). A search of the prescribing information did not specifically list weight gain as a side effect. This is not a complete list of the side effects associated with Coumadin. Laura Cable, PharmD

A: Coumadin (warfarin) (http://http://www.everydayhealth.com/drugs/coumadin) is an anticoagulant that is indicated for prevention of blood clots after strokes, heart attacks, and as a prophylaxis treatment in atrial fibrillation. (http://www.everydayhealth.com/senior-health/stroke/index.aspx). 1) Coumadin-Food- Vitamin K foods may interfere with the effects of Coumadin. Vitamin K in founds in foods such as green leafy vegetables such as lettuce, soy beans and green tea. Vitamin K is also found in bacon, cheese, cauliflower, and coffee. Intake of vitamin K through supplements or diet should not vary significantly during Coumadin therapy. The diet should remain consistent in foods that contain vitamin K When your doctor prescribes a new medication, be sure to discuss all your prescription and over-the-counter drugs, including dietary supplements, vitamins, botanicals, minerals, and herbals, as well as the foods you eat. Always keep a current list of the drugs and supplements you take and review it with your health care providers and your pharmacist. If possible, use one pharmacy for all your prescription medications and over-the-counter products. This allows your pharmacist to keep a complete record of all your prescription drugs and to advise you about drug interactions and side effects. For more specific information, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. Kimberly Hotz, PharmD

Q: Three weeks ago, I was put on Coumadin for a recently Dx PE in my right lower lung. For the past week and a half, I have experienced sharp bone/muscle pain beginning in the arch of my left foot, up to ankle, around and up to my outter leg. My potassium checks are normal. Is the Coumadin a factor in this case? My INR is 1.4. To begin with I was put on Lovenox 80 mg twice daily for 7 days along with Coumadin.

A: Coumadin (warfarin) is used to help prevent and treat blood clots in the legs, lungs, and those clots associated with heart-valve replacement or an irregular, rapid heartbeat called atrial fibrillation. The most common side effect of warfarin is hemorrhage (bleeding). Patients should be advised to promptly report any signs of bleeding to their physician, including pain, swelling, headache, dizziness, weakness, prolonged bleeding from cuts, increased menstrual flow, vaginal bleeding, nosebleeds, bleeding of gums from brushing, unusual bleeding or bruising, red or brown urine, or red or black stools. For more detailed information, consult with your physician or pharmacist for guidance based on your specific condition and current medications. Shereen A. Gharbia, PharmD

Q: I take Coumadin, and it's causing an in-grown toenail and causing my big toe to throb. What can I do?

A: If you are asking about Coumadin (warfarin) that is used as a blood thinner (or anticoagulant), the following information is listed in the package insert. The most serious risks associated with Coumadin (warfarin) treatment are bleeding in any tissue or organ or death of skin and other tissues. Purple toe syndrome has also been reported. It is characterized by dark, purplish, or uneven spots of color on the toes. Patients should report any signs of bleeding to their health care provider at once. If this is not what you intended to ask and you would like to try again or submit a new question, please return to the Ask a Pharmacist page at http://www.everydayhealth.com/drugs/. For more information, please consult with your health care provider. Michelle McDermott, PharmD

Q: I am on Coumadin, and there is vitamin K in my Carnation breakfast drink. It says there is 25 percent. Is that too much?

A: Vitamin K does counteract the blood thinner effects of Coumadin (warfarin). The answer would depend upon how consistently you take the Carnation breakfast drink. If you feel that you do want to use this drink on a regular basis, it would be necessary for you to work with your physician to adjust your Coumadin dose to account for intake of the vitamin K. For more information on Coumadin, visit http://www.everydayhealth.com/drugs/coumadin.

Q: Can someone on Coumadin drink a beer?

A: According to the National Health Institutes (NIH), alcohol intake greater than 3 drinks per day can increase the effect of Coumadin. However, some doctors advise their patients taking Coumadin to avoid alcoholic drinks altogether based on patient-specific health factors. It is best to check with your doctor about specific recommendations based on your Coumadin dose and overall health. http://www.cc.nih.gov/ccc/patient_education/drug_nutrient/coumadin1.pdf

Q: My dad was recently put on Coumadin for an irregular heartbeat. A few weeks after he began taking it, he began to have pain in his right groin, thigh, and down to his calf. His right leg feels very weak, and he has a hard time getting up and down for sitting and stairs. Could this be a side effect of Coumadin? He's had sciatic pain once before many years ago. Do you think there could be a connection? The only time he has relief is when he takes a hot bath.

A: Coumadin (warfarin) is an anticoagulant used to thin the blood to prevent blood clots. The main possible side effect of Coumadin is bleeding. If you notice any type of bleeding while on Coumadin, you should contact your health care provider. It is possible for Coumadin to cause join or muscle pain and weakness, although these are not very common. Often the benefit of being on Coumadin to prevent a life-threatening blood clot is greater than the side effects it may cause. With pain in the leg there is a question of whether it could be due to a blood clot in the leg. Your health care provider will be able to determine if there is a potential blood clot. He/she will also be able to go over the risks and benefits of Coumadin with you. Please see the following Everyday Health link for more information on Coumadin. http://www.everydayhealth.com/drugs/warfarin. Laura Cable, PharmD

Q: What supplements are dangerous to take while taking Coumadin?

A: While on Coumadin, you should not take any supplements without first checking with your pharmacist or health care provider. Many supplement may have an affect on your INR levels and some may affect these levels that we do not know. Do not take any OTC herbals or vitamins without checking with your health care provider first. I have included a list for you plus a site you can visit for more information. http://www.everydayhealth.com/drugs/coumadin. In some cases, an herb or supplement may appear in more than one category, which may seem contradictory. For clarification, read the full article for details about the summarized interactions. Avoid these supplements when taking this medication since the supplement may decrease the absorption and/or activity of the medication in the body: coenzyme Q10, green tea, iron, magnesium, St. John's wort, vitamin C, zinc. Avoid these supplements when taking this medication because taking them together may cause undesirable or dangerous results: American ginseng, Asian ginseng, cranberry, dan shen, devil's claw, dong quai, fenugreek, garlic, ginger, ginkgo biloba, horse chestnut, lycium barbarum, papain, quilinggao, quinine, red clover, reishi sweet clover, sweet woodruff, vitamin D. Before taking any of these supplements or eating any of these foods with your medication, read the article for full details: alcohol, bromelain, Eleuthero, Olestra, protein, soy, vitamim C, vitamin E, vitamin K, bromelain.

Q: My INR level dropped. Could this be because I've been eating lots of zucchini and lettuce? I also missed one of my warfarin doses a couple of days ago.

A: INR (international normalized ratio) levels indicate the clotting tendency of the blood. Coumadin (warfarin) is an anticoagulant used in prevention of blood clots after strokes and heart attacks and as a prophylactic treatment in atrial fibrillation. Coumadin should be taken at the same time every day, either with or without food. If a dose is missed, take the missed dose as soon as you remember. Call the doctor as soon as possible after the missed dose. Eating large amount of foods high in vitamin K (such as liver, green leafy vegetables, or vegetable oils) can make Coumadin less effective, so you should consult with your doctor about any changes in your diet. For more information about warfarin, go to http://www.everydayhealth.com/drugs/coumadin. For more specific information about your specific situation, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. Kimberly Hotz, PharmD

Q: I'm taking Coumadin. Can I also take Excedrin?

A: Coumadin (warfarin) is a blood thinner used to prevent blood clots. Excedrin (acetaminophen, aspirin, and caffeine) is a headache pain reliever. Generally speaking, drug interactions fall into three main categories: Drug-drug interactions occur when two or more drugs react with each other. Drug-diet interactions result from drugs reacting with foods or drinks. Drug-disease interactions may occur when an existing medical condition makes certain drugs potentially harmful. Coumadin (warfarin) and Excedrin should not be taken together unless prescribed by your doctor. Excedrin contains aspirin; taking aspirin with Coumadin can greatly increase the risk of bleeding, including bleeding ulcers. Do not take this combination unless prescribed by your doctor. Be sure to tell your doctor if you have any signs of bleeding, such as bloody nose, bruising easily, or blood in urine or stool. For more specific information about your own situation, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. Laura Cable, PharmD, BCPS

Q: My INR jumped this morning. I take Coumadin for my atrial fibrillation. What are the possible causes for the spike in my INR?

A: The INR (international normalized ratio) level measures the tendency of the blood to coagulate. Coumadin (warfarin) is a blood thinner used to prevent the formation of blood clots, to prevent heart attacks and strokes. When you're on warfarin, your doctor must monitor your INR levels to ensure that your blood is not too thin, which can lead to an increased risk of internal bleeding. Warfarin may interact with many other medications, herbs, supplements, vitamins, and minerals. It's important to discuss all medications, even over-the-counter products, with your healthcare provider. Some medications can affect blood clotting and may lead to bleeding in the stomach or intestines. Some medications that are known to have this effect are Tylenol (acetaminophen), aspirin, Motrin/Advil (ibuprofen), and Aleve (naproxen). Many foods can also cause changes in the INR. Vitamin K, which decreases the effects of warfarin, is found in many green, leafy vegetables, such as broccoli, Brussels sprouts, spinach, and cabbage. Alcohol, on the other hand, can increase the effects of warfarin and should also be avoided. Also, changes in the liver function may cause changes in INR readings. As you can see, many different factors can influence the INR level. It's best to keep diet and medications consistent and monitor the INR regularly. Also be aware of any bruising, as this may be a sign of internal bleeding or blood that's too thin. For more specific information about your particular situation, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. Megan Uehara, PharmD

Q: I take 5 mg Coumadin daily. I seem to have lost my energy and feel tired all the time since I started taking it. I also find it very difficult to lose weight even though I force myself to keep up with my exercise regimen. Is Coumadin known for these symptoms?

A: Coumadin (warfarin) is an anticoagulant (blood thinner) that reduces the formation of blood clots. It is used to prevent heart attacks, strokes, and blood clots in veins and arteries. Common side effects of warfarin include nausea, vomiting, stomach pain, gas, and bloating. Bleeding may also occur with Coumadin. Signs of bleeding include nose bleeds, bleeding gums, unusual or easy bruising, cuts that won't heal, and dark urine or stool. This is not a complete list of side effects that can occur with Coumadin. The prescribing information for Coumadin listed fatigue or tiredness as an infrequent side effect. However, a search of a drug database and the prescribing information for Coumadin did not specifically list weight gain or difficulty losing weight as a side effect. Consult your doctor or health care provider for proper evaluation of these symptoms. For more specific information, consult with your doctor or local pharmacist for guidance based on your health status and current medications, particularly before taking any action.
Sarah Lewis, RPh, PharmD

Q: What vitamins and minerals can I take with Coumadin?

A: According to the National Institutes of Health, the best way to get enough vitamins is to eat a balanced diet with a variety of foods. In some cases, a daily multivitamin may be needed for optimal health. There are numerous formulations and different combinations of vitamins and minerals. The need for vitamin supplementation and the choice of the most appropriate vitamin preparation may depend on many patient-specific characteristics. Thus, it is important to consult with your physician or health care provider regarding the intake of vitamins. Because herbs and supplements are not strictly regulated by the U.S. Food and Drug Administration, these products are not required to be tested for effectiveness, purity, or safety. It is generally okay to take a multivitamin/multimineral daily while on Coumadin (warfarin) but it is important to talk with your doctor. Any change in the amount of vitamin K (which is found in multivitamins) you have can make a difference in the Coumadin dose you need so your blood work may need to be checked soon after starting a multivitamin. In general, dietary supplements should only be taken under the supervision of your health care provider. For more specific information, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action.
Laura Cable, PharmD, BCPS

Q: What kind of analgesics can I take while I am on Coumadin?

A: While all analgesics do pose some form of risk to Coumadin therapy, Tylenol (generic name acetaminophen) would be the safest to use. NSAIDs (like Advil, Aleve and aspirin) should be avoided unless directed to be used by your physician. Of course, it is always a good idea to check with your doctor prior to taking any medication since INR levels can be very sensitive. Megan Uehara, PharmD

A: Coumadin is an effective medication that is easily quantifiable. We can determine how much Coumadin (warfarin) to give to get an intended blood-thinning potential. That can't be done with omega-3 capsules. For more information about Coumadin, go to http://www.everydayhealth.com/drugs/coumadin. Matt Curley, PharmD

Q: I take Coumadin 10 mg. My wife bought potato chips today. They have vitamin K in them. Is it okay to eat some when I'm on Coumadin?

A: The main dietary concern of taking Coumadin (warfarin) has to do with the amount of vitamin K in your diet. Vitamin K changes the way Coumadin affects the blood. When you eat foods that are high in vitamin K, you can decrease the effect of Coumadin. Likewise, eating less vitamin K can increase the effect of the medication. The key is to try to eat a similar amount of foods that contain vitamin K each day. Don't make any major changes to your diet without speaking with your doctor. You can also find helpful information on Coumadin at http://www.everydayhealth.com/drugs/coumadin.

Q: Should I take Coumadin with my other medications, or should I take by itself?

A: It is recommended that each dose of Coumadin (warfarin) be taken with a full glass of water at the same time each day or as prescribed by your doctor. Your Coumadin dose can be taken with or without food. The manufacturer of Coumadin makes no warnings that Coumadin should not be taken with other medications, vitamins, or supplements. Talk to your doctor about concerns you have with specific medications you are taking. Do not start or stop any medications or treatments without first talking to your doctor. I believe you will find the following links at everydayhealth.com also very helpful for your current situation. http://www.everydayhealth.com/drugs/coumadin/dosage'>http://www.everydayhealth.com/drugs/coumadin/dosage (how to take it) http://www.everydayhealth.com/drugs/coumadin (general info).
Jennifer Carey, PharmD

Q: Is Coumadin causing my fatigue?

A: Fatigue is listed as a common reaction to or side effect from taking Coumadin (warfarin). However, side effects are very patient specific. Take each dose with a full glass of water. Take warfarin at the same time every day. Warfarin can be taken with or without food. Click on the following link for additional information: http://www.everydayhealth.com/drugs/coumadin.
Lowell Sterler, RPh

Q: What are the side effects of Coumadin?

A: Coumadin (warfarin) is an anticoagulant that helps to prevent the formation of blood clots. Some of the more common side effects associated with Coumadin are bleeding, bruising easily, abdominal cramps, nausea, vomiting, diarrhea, gas, fatigue, headache, dizziness, taste changes, itching, fever, cold intolerance, and hair loss. This is not a complete list of the side effects associated with Coumadin. Megan Uehara, PharmD

Q: When my INR reading is higher than normal, should I take more or less Coumadin?

A: INR (International Normalized Ratio) involves a blood test that measures the clotting ability of the blood. For patients that are taking an anticoagulant medication, the recommended INR is usually 2.0 to 3.0. However, in patients that have a high risk for the formation of clots, the INR may need to be set higher, approximately 2.5 to 3.5. Your physician can recommend what level your INR should be at. A high INR result means that it takes longer for the blood to clot. This means that the Coumadin (warfarin) dose is likely too high. A high INR puts a patient at risk for serious bleeding issues. However, all dosage adjustments should be done by your physician. Do not stop taking or change the dose of your medication without talking to your physician first. Jen Marsico, RPh

Q: What will happen if I have a spinach salad with cranberries in it while taking Coumadin? Would the two foods cancel each other out?

A: Although cranberry can interact with Coumadin (warfarin), possibly causing an increase in how long warfarin stays in the body, and foods that are high in vitamin K, such as spinach can decrease the effect of warfarin, eating these foods together will not cancel each other out. But if you like cranberries on your spinach salad, it should be okay for you to have as long as you eat a small one, consistently, every day. But first, consult with your physician before changing your diet while you are taking Coumadin. Most health care professionals agree that the most important aspect of diet and vitamin K intake, while on Coumadin, is to keep it consistent. Coumadin inhibits the action of vitamin K dependent blood clot formation. It is very important to maintain a consistent level of vitamin K intake while taking Coumadin. Large amounts of vitamin K are found in foods such as liver, broccoli, brussels sprouts, spinach, Swiss chard, coriander, collards, cabbage, and other green leafy vegetables. Changing the amount of these foods in your diet will affect the level of Coumadin in the body. Be sure to have your Coumadin level checked regularly by your physician, especially if you change the amount of vitamin K in your diet or start any new medications or supplements that can interact with Coumadin. For more specific information, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. Burton Dunaway, PharmD

Q: My husband is on Coumadin and recently started taking organic cayenne pepper powder. Will this interfere with the Coumadin?

A: Coumadin (warfarin) is an anticoagulant that is indicated for the prevention of blood clots after strokes, heart attacks, and as a prophylaxis treatment for patients with atrial fibrillation. Coumadin works by blocking the synthesis of clotting factors. Without the clotting factors, blood clots cannot form. Coumadin should be taken at the same time every day either with or without food. If a dose is missed, take the missed dose as soon as you remember. Call the doctor as soon as possible after the missed dose. Common side effects associated with Coumadin include nausea, stomach pain, gas and bloating. Cayenne pepper powder is thought to be beneficial for a variety of health conditions such as poor circulation, heart disease, chronic pain, headaches, and toothaches. Cayenne pepper powder is classified as a supplement, or herbal remedy, and not approved or regulated by the U.S. Food and Drug Administration (FDA). It is thought that cayenne may increase the risk of bleeding in patients treated with an anticoagulant, such as Coumadin. However, the side effects and possible drug interactions of cayenne pepper powder has not been proven because there are no clinical trials to provide evidence. Also, without regulation from the FDA, the safety and effectiveness has not been established. It is important to tell the doctor if over-the-counter products are taken including herbals, vitamins, and supplements. The doctor can determine if the over-the-counter therapy if necessary. Also, if the cayenne does affect the anticoagulant effects of the Coumadin, the doctor can more closely monitored the INR. First talk to the doctor for more specific information on the use of the cayenne powder with the Coumadin. Kimberly Hotz, PharmD

Q: My sister is on Coumadin. However, her blood test INR has been around 1.3 for the past few weeks. I am concerned that the doctor is going to raise the dose. Is there any food she can consume to up the INR level?

A: Coumadin (warfarin) is an anticoagulant or blood thinner. Coumadin works by blocking the formation of clotting factors in the blood. Coumadin is used to treat or prevent blood clots that may form in people with certain medical conditions. This includes atrial fibrillation (an abnormal heart rhythm), heart valve replacements, pulmonary embolism (PE), deep venous thrombosis (DVT), and heart attack. The dosing of Coumadin is very individualized and is based on a laboratory test called the International Normalized Ratio (INR). Some people are very sensitive to the effects of Coumadin and may require only small doses to reach their goal INR. However, other people may require higher doses in order to reach their goal. Regardless, the focus of Coumadin treatment should be on reaching the goal, which may take frequent dose adjustments, not maintaining one dose or trying to prevent a dose adjustment. Patients on Coumadin should not make any changes to their diets without talking to their healthcare provider first, as this could lead to serious or life-threatening effects. Vitamin K is the primary dietary factor that affects Coumadin. Too much vitamin K can lead to the formation of blood clots which can cause heart attack and stroke. However, decreasing the amount of vitamin K in the diet can lead to bleeding, hemorrhages, and stroke. Patients on Coumadin should contact their healthcare provider right away if they experience any signs of bleeding, such as nosebleeds, bleeding gums, easy or unusual bruising, cuts that won't clot or stop, and bloody or dark urine or stool. For more specific information, consult with your doctor or local pharmacist for guidance based on your health status and current medications, particularly before taking any action. Sarah Lewis, PharmD

Q: My INR was too high after hip surgery and I was told a drug was used to reverse it. What is the name of the drug and what are the side effects? They resumed Coumadin recently while I was still in hospital and they are monitorning my blood daily. Is it still safe to continue taking it?

A: INR, or international normalized ratio, is a blood test done to check how thick or thin the blood is. INR is used to monitor Coumadin (warfarin) therapy. Coumadin is a blood thinner used to prevent blood clots in patients with a history of clots or certain heart conditions. Patients on Coumadin will need regular testing of INR to ensure the current dose of Coumadin is optimal. Blood that is too thick may lead to blood clots and blood that is too thin may lead to bleeding. Many patients on Coumadin will have a goal INR of 2.0 to 3.0. However, some patients, such as those with certain heart valves, will have a higher goal of 2.5 to 3.5. The higher the INR, the thinner the blood, and the lower the INR the thicker the blood. If your INR is too high, meaning your blood is too thin, your doctor may prescribe vitamin K (phytonadione) to help lower your INR. Vitamin K can also be given as an injection. You should not take vitamin K without your doctor instructing you to do so. Most patients tolerate vitamin K without any side effects. Some potential side effects of vitamin K include low blood pressure, rapid or weak pulse, sweating, flushing, and shortness of breath (side effects are more common with the vitamin K injection than any other type of formulation). If an elevated INR does not result in any adverse events, it is common to restart Coumadin once the INR has returned to the desired range. Coumadin will likely be restarted at a lower dose. Changes in diet, especially vitamin K found in green leafy vegetables, or changes in medications, and alcohol intake can change an INR reading. It is important to consult with your healthcare provider regarding which dose you should take based on your INR readings. Discuss any changes in diet or medications with your healthcare provider. It is also important to report any signs of bleeding to your healthcare provider. Be sure to inform your doctor and pharmacist of all the medications you take, including over-the-counter medications, vitamins, and herbal supplements, so they can monitor for drug interactions. It is also important to discuss any side effects you experience from medications with your doctor. For more specific information, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. Laura Cable, PharmD

Q: I was on Coumadin for a blood disorder called anticardiolipin antibodies and had severe nosebleeds. My cardiologist switched me to Pradaxa, which has only been approved for atrial fibrillation and the hematologist disagrees. Can Pradaxa be used for my blood disorder?

A: Pradaxa (dabigatran etexilate) is not currently approved, by the U.S. Food and Drug Administration (FDA), for the treatment of anticardiolipin antibodies. Medications are sometimes prescribed, for off-label use, for certain conditions that are not mentioned in the prescribing information. Off-label uses of a medication have not been approved by the FDA. If you would like more information, speak with your doctor. Pradaxa is classified as a direct thrombin inhibitor approved, by the FDA, for the prevention of stroke and blood clots in patients with non-valvular atrial fibrillation (abnormal heart rhythm). Pradaxa blocks the enzyme in the blood which is involved in blood clotting. According to the prescribing information, the most commonly reported side effects include gastritis-like symptoms and bleeding. Gastritis-like symptoms may include dyspepsia (upset stomach, indigestion), stomach pain, nausea, heartburn and bloating. Pradaxa does not require the routine monitoring necessary in patients being treated with Coumadin (warfarin). However, similar to other anticoagulants, Pradaxa can cause serious, and potentially fatal, bleeding. Proper monitoring and evaluation of signs and symptoms of bleeding are essential. In a clinical trial, comparing Pradaxa to warfarin, patients being treated with Pradaxa had fewer strokes. It is important to take Pradaxa exactly as directed by your health care provider. Swallow Pradaxa whole. Do not chew, break or open the capsules. Pradaxa may be taken without regard to food. For more specific information, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. Beth Isaac, PharmD

Q: If you are taking Coumadin, and cannot eat any vitamin K, can that cause your potassium to get low? Can it also make your eyes hurt and have blurred vision?

A: Vitamin K can decrease the blood thinning effects of Coumadin (warfarin). According to the prescribing information for Coumadin, the amount of vitamin K in food may affect therapy with Coumadin. It is recommended that people consume a normal, balanced diet, which includes a consistent amount of vitamin K. The prescribing information for Coumadin further states that people should avoid drastic changes in dietary habits, such as eating a lot of green leafy vegetables. Other foods that contain large amounts of vitamin K are liver, broccoli, Brussels sprouts, spinach, certain vegetable oils, Swiss chard, coriander, collards, and cabbage. It is recommended that people taking Coumadin should avoid consumption of cranberry juice or other cranberry products as these products can increase the effects of Coumadin. People should tell their doctor if these foods are part of their diet. Vitamin K and potassium are not the same. Please consult with your health care provider in regards to your potassium level and the symptoms of blurred vision and painful eyes you are experiencing. For more specific information, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. Kristen Dore, PharmD

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